Provider Demographics
NPI:1164405981
Name:JANI, RUTKUMAR P (MD)
Entity Type:Individual
Prefix:
First Name:RUTKUMAR
Middle Name:P
Last Name:JANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-419-4949
Mailing Address - Fax:
Practice Address - Street 1:229 LONGTOWN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8550
Practice Address - Country:US
Practice Address - Phone:803-419-4949
Practice Address - Fax:803-419-6445
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC154095Medicaid
SCE97398028Medicare ID - Type Unspecified
E97398Medicare UPIN